Removing the stigma, integrating the patients


Mental health-care professionals are looking to transform the Czech Republic's psychiatric care system on two fronts: Firstly, by launching a campaign to de-stigmatise diseases like schizophrenia and depression, and secondly by moving towards community based care.

An ambitious project is getting underway to improve care for people with psychiatric problems. Drawn up by leading medical professionals, Project Zmena, or "Change", aims to integrate mentally ill people into the community at large — rather than placing them in institutions — and to educate the general public about the nature of these conditions.

During the first year, the project will concentrate on "demystifying" schizophrenia, which, according to project manager Barbora Wenigova, is the most stigmatised disease. In 2006, Project Zmena will focus on depression and, in 2007, on mental health problems common to children and adolescents.

"These illnesses were chosen because they're the most often stigmatized. Schizophrenia has the most negative associations. When we think of an awful mental condition, something bizarre — something 'crazy' — very often it is schizophrenia. So, to start with, we will concentrate on these conditions."

A long-time advocate of community based care, Dr Graham Thornicroft of the London-based Institute of Psychiatry, who consulted on the Czech initiative, says that it's is in line with international trends and best practices — and so a step in the right direction.

"The plans of the World Health Organisation for mental health are very clear. In the World Mental Health Report, they made it clear that they should include anti-stigma activities and move mental health-care services progressively away from the large institutions, away from the big asylums, to smaller facilities in the community. Why do that? Because it provides a more humane form of care, and we've now seen from a lot of research studies that it's both more effective — and more cost effective — to produce community rather than hospital care."

Less than 4 percent of the Czech Republic's health-care budget goes towards mental-health care, about one-third of what the World Health Organisation estimates is needed. But reforming the mental health-care system and agreeing on an overall budget is especially complicated as it involves two ministries. Psychiatric care falls under the Health Ministry, while the Ministry of Social Affairs is responsible for residential care for people with mental disabilities.

Czech psychiatrist and patients' rights advocate Dr Jan Pfeiffer says that Project Zmena also is aimed at getting a clear picture of just how the money is spent.

"The problem is that it's quite difficult to find out how much money we [actually] have, because our system is very fragmented, that is, with no one clearly responsible. We really need to have clear coordination and cooperation between the responsible stakeholders. The essential problem with money, and how we use the funds, is that the money is not stimulating any changes; it is just conversing things as they are."

A former president of the World Psychiatric Association, Prof Norman Sartorius, says that while project Zmena may not seem "revolutionary", working for gradual change in the Czech system is actually the best way to go.

"It has been called a 'transformation' — and that's an important point, because what we want to see is a change, but not a wild reform in which — without experience — we suddenly move to something else. Rather - using the best knowledge that we have - gradually introduce changes, correct as we go, and then, in the course of a few years, arrive at the new form of service, where there will be parity between patients with mental illnesses and patients who have other types of illnesses."

Perhaps "parity" is the word that best describes the aim of the project: securing proportionate funding and stigma-free treatment for those suffering from physical or mental illnesses. Dr Thornicroft again.

"I think we want to see a day when mentally ill people are treated with equality. So, would we use caged beds for people with diabetes or epilepsy? I think not. We have to pay close attention to the human rights of all patients."